CHAPTER 7 ANTERIOR TORSO COMPARTMENT (ATC)

Transcription

1 CHAPTER 7 ANTERIOR TORSO COMPARTMENT (ATC)

2 CLINICAL MASSAGE THERAPY AND STRUCTURAL BODYWORK 165 LEARNING OUTCOMES After completing this chapter, you will be able to: 7.1 Define the origins and insertions of the muscles of the ATC. 7.2 Describe the actions of the ATC. 7.3 Recognize the pain patterns of the ATC. 7.4 Discuss the clinical notes for and the importance of treating the muscles of the ATC. 7.5 Demonstrate the client positioning and treatment routines related to the ATC 7.6 Demonstrate safe and effective stretching techniques for the muscles of the ATC. OVERVIEW Like the posterior lower extremity compartment (PLEC), the anterior torso compartment (ATC) includes muscles that pull the rib cage down, flatten the lumbar spine, compress the lumbar and cervical disks, and entail many muscular imbalances that cause stooped posture and pain. Shortened abdominal muscles will pull the rib cage down and cause a forward neck and head positioning (FHP). Often, this downward collapsed, stooped posture will reverse the cervical curvature of the spine and compress the lower cervical disks and suboccipital joints, subsequently decreasing cervical range of motion and many back, shoulder, and upper-extremity pain syndromes. The extensors of the lumbar and cervical spine and the retractor muscles of the scapulae often are tighter, produce the most trigger points, and elicit the most pain. It is these posterior compartment muscles that countertighten and resist the forward and downward pulls of tension from the shortened trunk flexors and hip extensors. (An analogy: A tree is held up with guide wires and the tree bends to one side from sustained winds it is the lengthened wires that become tighter as they resist the weight of the tree being pulled over by the wind.) The abdominals, psoas, serratus anterior, pectorals, and anterior cervicals are a kinetic chain that, when short, often causes chronic pain of the low back, neck, and shoulders. Often, chronic back, neck, and shoulder pain associated with muscular imbalances that effect stooped posture can be reduced and even eliminated with treatment to the short muscles in the anterior torso, rather than the painful ones often experienced in the posterior torso. Lengthening the abdominals will create space between the pelvis and the rib cage. Lengthening the serratus anterior and pectorals will create space between the shoulder girdles and the pelvis, thereby allowing the scapulae to drift up and back, restoring the body to a more upright posture. Treatment for stooped posture and forward neck and head positioning should consist of combining both the abdominals and the hamstrings within each session. Lengthening the hamstrings will cause the pelvis to rotate up and forward, increasing the lumbar curve and thereby greatly reducing the compression effect on the lumbar spinal disks. The combined treatments (ATC and PLEC) will restore the body to an upright posture, thereby decreasing the chronic pain that is often experienced in the posterior torso.

3 166 CHAPTER 7 ANTERIOR TORSO COMPARTMENT (ATC) Note: The anterior torso is the emotional cylinder of the body. Playing the edge with precision and focused intent will allow the client to stay relaxed and allow you to have deeper access into the deeper layers of the abdominal wall. Precise hand placements and treatment routines of the abdominal, chest, and anterior cervical muscles are clearly covered in this chapter to teach students how to work in these sensitive and emotional areas. The ATC therapy routines show students how to develop their skills and will help students become proficient when working with clients whose back and neck pain is the result of muscular imbalances and stooped posture. CLINICAL SUCCESS In 2001, a professional golfer on the PGA tour went to a therapist. He complained of a slight numbness in his fingers with a considerable amount of decreased grip strength of his hands. Over the course of 3 years, this client had seen numerous health care specialists and been told that he probably had a neck stinger. The therapist believed that the man s complaint was the result of cervical disk compression, irritating the nerve roots at the C4 through C7 levels, as well as entrapment of the nerve supply exiting the soft tissues of his anterior and lateral neck. During a soft-look evaluation of the client s body, the therapist observed his projected forward head posture and suboccipital compression at the base of the occiput. He was a right-handed golfer and displayed a dropped right shoulder girdle and a locked short abdominal wall. He also had a significant number of muscular imbalances throughout his body. His primary complaints related to tingling, numbness, and weak grip strength; however, to achieve lasting results, it was necessary to address the imbalances that affected his overall posture. The client was placed in the supine position on the table and a hard-look evaluation of his body was conducted. After thoroughly examining for lower-body deviations, the therapist concluded that the client s leg lengths and pelvic bones were symmetrical and that his primary complaint of bilateral upper-extremity numbness and weakness was most likely isolated in the neck and the thoracic outlet. The client was moved into a side-lying position aided by a cushioned body support system. The treatment plan consisted of releasing the anterior cervical muscles, primarily the longus colli, the longus capitis, and the scalene muscles. Releasing these muscles would help restore much of his cervical lordosis, thereby reducing the compression effect on his spinal nerves and at the base of the occiput. The muscles attached on the anterior tubercles were isolated, and the therapist proceeded to apply slow, deep compression to the scalene muscles; this triggered referrals down the client s arm and hand. The therapist treated the client bilaterally with a 2:1 ratio, spending more time on the left elevated side; the client s posterior suboccipital muscles were released. This corrected the positioning of his tilted head and increased his cervical range of motion. A total of 6 hours in 3 days was spent restoring symmetry to his thoracic and cervical muscles. Slow, focused, and isolated work in the appropriate areas produced remarkable results. These results were leveled shoulder girdles, lengthened abdominal muscles with increased fluid trunk rotation, a substantial increase in cervical hyperextension and rotation, and full reduction of symptoms in his hands and better overall posture. The client experienced no discomfort during the therapy sessions and no residual discomfort during his tournament play.

4 CLINICAL MASSAGE THERAPY AND STRUCTURAL BODYWORK 167 ABDOMINALS RECTUS ABDOMINIS, FIGURES 7.1 AND 7.2 ORIGIN Costal cartilages 5, 6, and 7 INSERTION Anterior pubic bone ACTION Flexes vertebral column; compresses abdominal contents MYOTOME T7 T12 EXTERNAL OBLIQUE, FIGURES 7.3 AND 7.4 ORIGIN Lower eight ribs INSERTION Abdominal fascia, iliac crest, and linea alba ACTION Bilaterally: flexes trunk; compresses abdominal contents Unilaterally: laterally flexes trunk; rotates trunk to opposite side MYOTOME T8 T12 Rectus abdominis Pyramidalis FIGURE 7.1 Rectus Abdominis Muscles

5 168 CHAPTER 7 ANTERIOR TORSO COMPARTMENT (ATC) Rectus abdominis pain patterns Rectus abdominis pain patterns FIGURE 7.2 Rectus Abdominis Muscle and Referred Pain Patterns External oblique (cut) Internal oblique Transverse abdominis Rectus abdominis FIGURE 7.3 External and Internal Obliques and Transverse Abdominis Muscles External oblique pain pattern External oblique pain pattern FIGURE 7.4 External Oblique Muscle and Referred Pain Patterns

6 CLINICAL MASSAGE THERAPY AND STRUCTURAL BODYWORK 169 INTERNAL OBLIQUE, FIGURES 7.3 AND 7.5 ORIGIN Inguinal ligament and iliac crest INSERTION Costal cartilages of last four ribs, abdominal fascia, and linea alba ACTION Bilaterally: flexes trunk; compresses abdominal contents Unilaterally: laterally flexes trunk; rotates trunk to same side MYOTOME T8 T12 TRANSVERSE ABDOMINIS, FIGURES 7.3 AND 7.6 ORIGIN Inguinal ligament, iliac crest, and thoracolumbar fascia INSERTION Abdominal fascia, linea alba, and pubis ACTION Compresses abdominal contents MYOTOME T7 T12 Internal oblique pain pattern Internal oblique pain pattern FIGURE 7.5 Internal Oblique Muscle and Referred Pain Patterns

7 170 CHAPTER 7 ANTERIOR TORSO COMPARTMENT (ATC) Transverse abdominis pain pattern FIGURE 7.6 Transverse Abdominis Referred Pain Pattern CLINICAL NOTES: Abdominals The abdominal muscles lie in the following order from superficial to deep: rectus abdominis, which runs superior to inferior; external oblique, which travels toward the midline; internal oblique, which travels away from the midline; and transverse abdominis, which travels horizontally around the abdominal contents. The abdominals work together to compress the abdominal contents and hold them in place. The transverse abdominis, being the primary, deepest abdominal muscle, creates a proper and true, noncompressive extension of the lumbar spine, or proper lordosis. The transverse abdominis also lifts the rib cage upward, taking the pressure off the lumbar vertebrae (decompressing the lumbar vertebrae by about 30 percent), and is the prime assister of complete exhalation. The rectus abdominis attaches midline to the rib cage and travels vertically to the pubic bone; therefore, it is the prime flexor of the trunk at the waistline. The internal oblique rotates the trunk toward the same side, while the external oblique rotates the trunk toward the opposite side; therefore, the internal and external obliques are synergistic to each other on opposite sides and antagonistic to each other on the same side. Both the internal and external obliques also contribute to lateral flexion of the trunk; rectus abdominis flexes the vertebral column. Any sustained pain (acute or chronic) of the abdomen should be referred to a primary care physician for proper medical and diagnostic evaluation. Abdominal pain can be the cause or result of a somatic-visceral response or a visceral-somatic response. In other words, it is very difficult to determine if the underlying problem is within the internal organs or the muscles, bones, and so on.

8 CLINICAL MASSAGE THERAPY AND STRUCTURAL BODYWORK 171 The primary referred pain pattern of the oblique muscles is in the upper abdominal quadrants just below the sternum; this pain is often confused with symptoms of gastrointestinal disturbances. Lower abdominal pain can also be associated with trigger point pain referring from the oblique muscles, which can facilitate pain into the groin and genitalia, thereby producing symptoms of urinary and bladder disturbances. Increased tension in the abdominal musculature can be the result of physical activities that require a vigorous full-body twisting motion, sit-ups and other similar abdominal exercises, chronic occupational strain, structural anomalies, and/or functional deviations of the pelvis or lower extremities. Shallow breathing is also a sign of tight abdominals. A seated-chair client is a person who spends most of the time sitting. Inadequate lumbar support over a long period of time, as seen in occupations that require sitting, will often cause a seatedchair client to slouch. Sitting slouched causes posterior rotation of the pelvis and loss of lumbar lordosis. This poor postural habit weakens the transverse abdominis, further facilitating the flattening of the lumbar spine. Even though the space is decreasing between the rib cage and the pelvis from slouched posture, the transverse abdominis is often left slack and often loses its ability to function properly. As the space between the rib cage and the pelvis decreases, so does the space for the abdominal contents. Loss of space increases the abdominal pressure and forces the abdominal contents to pooch out ; this further inhibits the function, maintaining lumbar lordosis. Slouched and stooped postures also involve the serratus anterior. The serratus anterior muscle is the primary protractor of the scapula, and its fibers interdigitate with those of the external oblique along the anterior-lateral rib cage. Protraction from the serratus anterior will cause the scapula to slide forward around the rib cage, further shortening the pectoral muscle and bringing the arm toward the chest; this is viewed as a rounded shoulder. It must be emphasized again that short trunk flexors and short hip extensors cause stooped posture and that, to avoid future problems, lengthening of the abdominals and hamstrings is essential in restoring the body to an upright physiologically efficient posture. Pain is a signal of abnormal physiology; and the signaling of pain is often a sign of neuromuscular exhaustion from chronic muscle and nerve tension and is frequently experienced in the lengthened posterior torso muscles of the lower back, neck, and shoulders. These frequently experienced pain symptoms are the body s way of communicating that it s tired of holding the body upright from the forward collapsing that is associated with stooped posture. The muscles of the posterior torso, primarily the extensors and retractors, countertighten in an effort to support the upper body and resist its falling forward off the gravitational line. Forward neck and head positioning resulting from stooped posture causes posterior neck pain, especially at the base of the occiput. Shortening of the posterior suboccipital muscles compresses the suboccipital joints, as this is the body s last-ditch effort to rock the head back, leveling the eyes to the horizon. These compressed joints often cause headaches and restrict cervical motion. Postoperative scar tissue in the abdominal area can be treated with massage therapy. Interweaving fascial bands around an incision site should be treated. However, reducing the muscle tension in the muscle bellies will ultimately produce better results, as releasing and lengthening the musculature will assist in the softening of the scar. Superficial work, including fascial stretching along the Langer

9 172 CHAPTER 7 ANTERIOR TORSO COMPARTMENT (ATC) lines, is very beneficial when the therapist is working with scarring. At the level of the waist and the abdomen, the Langer lines wrap around the body horizontally. Langer lines are lines of tension in the skin s elastic component due to the alignment of the collagen fibers in the dermis. They are used frequently in surgical procedures as a guide for cutting. If a cut is made along a Langer line, the scar is likely to be less severe; cutting across a Langer line will cause a more prominent scar. These lines often follow the skin s natural wrinkles. ROUTINE: Abdominals Position of client: supine. Any sustained pain (acute or chronic) of the abdomen should be referred to the primary physician for proper medical and diagnostic evaluation. 1. Treat the anterior torso compartment with compression, separating the muscle divisions from the pubic bone to the rib cage. (See Figure 7.7.) Continue superiorly through the sternal and pectoral regions in a fan-shaped pattern ending at the clavicles. 2. This is a bilateral treatment; if the leg lengths are even, choose one side to treat first. If the client s leg lengths are uneven, spend more time treating the shorter-leg side in a 2:1 ratio, as opening the space between the rib cage and the pelvis will often allow the pelvis to drop and the rib cage to raise up, often leveling the iliums and leg lengths. Find the midline border (linea alba), and begin treatment directly lateral to the midline and inferior to the rib cage, using compression and slow gliding to treat the rectus abdominis muscle ( Figure 7.8 ). Move inferiorly and continue static compressions making a total of four contact points before reaching the pubic bone. 3. Flex the trunk laterally, away from the side being treated. Move laterally into the obliques, and continue treatment with compression and slow gliding. Hold static compression at each contact when muscle tension is felt. Isolate approximately four contact points from the upper to lower abdominal wall. Treat each contact point with slow, deep compression while maintaining the client s edge. This allows the client to fully relax, thereby allowing you, the therapist, to proceed further into the deeper layers of the abdominal wall. (See Figure 7.9.) In FIGURE 7.7 FIGURE 7.8

10 CLINICAL MASSAGE THERAPY AND STRUCTURAL BODYWORK 173 FIGURE 7.9a FIGURE 7.9b FIGURE 7.9c FIGURE 7.9d Figure 7.9 d, the use of the elbow gives a broader contact point and a deeper compression into the muscles and should be practiced. Sitting in a comfortable position and leaning forward will allow you to sustain the broader compression for longer periods as well as rest your fingers. 4. Have your client turn to a side-lying position, arm extended over the head. Place a bolster in the space between the pelvis and the rib cage. Treat the lateral abdominal wall with myofascial stretching along the Langer lines with both hands moving horizontally down toward the table. (See Figure 7.10.) 5. Using the fingertips of one hand while stretching the myofascia with the other, treat the obliques with compression and myofascial stretching at the level of the waistline. Continue around the waistline from anterior to posterior, further treating the abdominals with compression and stretching. (See Figure 7.11.) Treat slowly, following the client s edge. 6. Using the thumbs, treat the muscles attaching to the rib cage with slow compression and friction. Opening up the spaces between the ribs will allow a fuller expansion of the rib cage on deeper inhalation. (See Figure 7.12.) Coach the client in deep breathing, and encourage the client to focus on full relaxation. Maintain the client s edge to avoid any pain or increased discomfort while continuing treatment throughout the anterior and lateral rib cage. FIGURE 7.10 FIGURE 7.11 FIGURE 7.12

11 174 CHAPTER 7 ANTERIOR TORSO COMPARTMENT (ATC) ILIOPSOAS PSOAS MAJOR, FIGURES 7.13 AND 7.14 ORIGIN INSERTION ACTION MYOTOME Vertebral bodies, intervertebral disks, and anterior transverse processes of T12 L5 Lesser trochanter of femur Flexes hip; flexes lumbar vertebrae; controls rate of extension of lumbar vertebrae; proximates lumbar vertebrae toward femur L1 L4 ILIACUS, FIGURES 7.13 AND 7.14 ORIGIN Inner surface of iliac fossa INSERTION Lesser trochanter of femur ACTION Flexes hip MYOTOME L2, L3 Psoas minor Psoas major Iliacus FIGURE 7.13 Iliopsoas Muscles: Psoas Major, Psoas Minor, and Iliacus

12 CLINICAL MASSAGE THERAPY AND STRUCTURAL BODYWORK 175 Iliopsoas pain pattern Iliopsoas pain pattern FIGURE 7.14 Iliopsoas Muscles and Referred Pain Patterns CLINICAL NOTES: Iliopsoas The iliopsoas is composed of two distinct muscles: the psoas major and the iliacus with one common attachment. The psoas major arises from the lumbar vertebrae. The iliacus originates from the inner surface of the iliac fossa and is well established as the primary hip flexor. They both insert on the lesser trochanter of the femur. Psoas major is the only muscle that attaches the lumbar spine to the femur. Many people think of the psoas as a primary postural stabilizer of the spine. Although it is often recruited as a postural stabilizer, that is not the proper or best use of the musculature. Other muscles are far more suited to this stabilizing function. If the overall structure remains open or decompressed and the posture is properly balanced in gravity, the psoas remains free to do its primary job, which is to produce, assist, and accommodate movement and action. Functions of Psoas There is no debate that the psoas major is a hip flexor. Yet there is much debate among researchers as to whether the iliopsoas is a flexor or an extensor of the lumbar spine. Part of the confusion is that the psoas major is a hip flexor, and hip flexion is usually associated with, and often to some degree causes, increased lumbar extension or lordosis. As hip flexors rotate the pelvis anteriorly, the pelvis draws the spine forward with it. All things being otherwise equal, the lumbar vertebrae would most likely fan forward into a lordosis. Other muscular factors, however, resist this action. (For clarification, it should be noted that the lifting of the femur toward the pelvis and the tilting of the pelvis down toward the femur are both, technically speaking, the same action: flexion of the hip. More precisely, hip flexion is a closing or decreasing of the angle between the femur and pelvis toward the front of the joint. Conversely, a posterior tilt of the pelvis is hip extension. Learning to think about joint movement in this fashion increases the student s ability to analyze posture and structure more precisely and efficiently.) A number of factors influence the various actions of the psoas muscles. When the psoas contracts, it draws the femur up toward the spine, assuming that the spine is more stabilized than the femur.

13 176 CHAPTER 7 ANTERIOR TORSO COMPARTMENT (ATC) If, however, the femur is more stabilized than the spine, the psoas draws the spine toward the femur, causing the spine to flex forward. An increase in lumbar lordosis is by definition an increase in the curve of the lumbar spine. In a true lumbar lordosis, the vertebral bodies must be able to fan open toward the front of the abdomen, which is why true lumbar lordosis is synergistic with the chest, head, and neck moving up and back, not forward and down. When viewed from the side, the psoas major lies in an almost vertical line along the lumbar spine and must pull each vertebral body downward toward the pelvis and femur. When this occurs, the psoas is actually decreasing the space between the vertebral bodies; flattening the lumbar arc. If there is a decreasing arc or arch in the lumbar spine, the vertebral bodies move closer to each other and the spinal disks are compressed. The overall spine moves forward and downward toward the femur; the lumbar vertebrae do not fan open to create lumbar extension they close, creating lumbar flexion. The psoas major muscle is, therefore, with a minor but significant exception at the L5-S1 joint (discussed later in this chapter), primarily a lumbar flexor. The psoas major does not create true lumbar extension or contribute to an actual lumbar lordosis; it actually resists it. Psoas Controls Lumbar Extension If the torso starts to lean backward, the psoas major will generate an eccentric contraction (a controlled lengthening by gradually reducing the level of tension) to prevent the spine from lengthening too far and too fast. Psoas Reacts to Other Muscles If the body is slouching forward and the abdominal wall and hip extensors are chronically short, it is far more common for the lumbar spine to be forced posteriorly and into chronic flexion. This draws the lumbar vertebral bodies toward each other, increasing compression of the spinal disks. In response to the lumbar spine being pushed posteriorly (rearward) and the pelvis moving into a posterior tuck, the psoas major, being a hip flexor, contracts in an attempt to counteract the posterior pelvic tilt and flattening of the lumbar spine. But at this point, psoas is incapable of actually accomplishing this counteraction. Yet in its attempt to do so, the psoas major contracts across the vertical line through the lumbar vertebrae. If indeed it is determined that psoas is contracted by way of reacting to overshortening of the hip extensors and abdominal wall, then, in therapy, one must release the abdominal flexors the rectus abdominis, and external and internal obliques and hip extensors hamstrings, adductor magnus (long portion), gluteals, deep rotatores to a significant degree before attempting to release the psoas major muscles. In many cases treating the psoas major without first addressing these muscles either ensures that the problem will quickly return or makes the problem worse in the long run. Compression of Lumbar Spinal Disks To reiterate, the psoas major muscle is perfectly placed to apply direct powerful downward forces that actually compress the lumbar vertebral bodies. This is a flexion, not an extension, of the lumbar spine. As the vertebral bodies compress and move toward each other, the disks in between the

14 CLINICAL MASSAGE THERAPY AND STRUCTURAL BODYWORK 177 vertebral bodies must be compressed as well. This is, potentially, a common cause of long-term chronic disk degeneration from slight narrowing to total herniation and rupture. This condition often produces no pain, which is why it is often doubtful that compression of disks is necessarily the cause of back pain. Other than cases in which the disk protrudes back into the spinal canal and/ or the neural foramina, the disks seldom have an opportunity to be the direct cause of pain. Much back pain is caused by muscles irritating and sometimes entrapping sensory nerves. Many nerves run through and behind the psoas muscles and are subject to irritation and compression. M uscle tension also produces vertebral dysfunction and disk pathology often from muscles distant from the posterior torso, such as the hamstrings, gluteals, and abdominal muscles. The Pars Vertebralis of Psoas The pars vertebralis portion of the psoas consists of small slips of muscle, which are the deepest layers of the psoas major, linking from the 12th thoracic vertebra to the lumbar vertebral bodies (T12 through L5). This usually unnoticed portion of the psoas major is a direct flexor of the lumbar vertebral column and compressor of the intervertebral disks. (See Figure 7.15a.) The pars vertebralis portion of the psoas major and the deepest fibers of the main body of the psoas major are the most inaccessible layers. Applying low-dose, micro-movement stretching (various small and gentle arching movements of the lumbar spine) is a way to access these muscles, although stretching does not in all cases immediately create the necessary changes if the involved fibers are too traumatized. A short ened or traumatized psoas requires the approach of the minimum-edge technique, which often requires manual therapy to assist the psoas stretch. While it is true that the psoas major is, along with the iliacus, a primary hip flexor, it simultaneously is a lumbar flexor and actually limits or reduces lumbar extension, preventing true excess lordosis and sometimes eliminating it altogether. This is because the overall bulk, the most superficial portion of the psoas muscle, runs parallel with, and is also capable of compressing, the lumbar vertebrae. Mini- or Pseudo- Lordosis The minor but significant exception referred to earlier is produced by the structure of the L5-S1 joint. Because the 5th lumbar, as viewed from the side, appears as if it were positioned on a small, downward-sloping shelf projecting forward from the top of the sacrum, the psoas major can also be a powerful force pulling the 5th lumbar vertebra, and the whole lumbar column, forward and down. It is common to have muscles pulling so hard in opposite directions that while the hip extensors attempt to rotate the pelvis posteriorly, the psoas attempts to rotate the lumbar spine anteriorly. This causes a forward and downward shearing action of the L5 vertebrae that creates a kink at the posterior face of the lumbosacral joint. The kink contributes to the illusion of the deep curve in the lumbar area. A quick look by an untrained eye can mistake this mini- or pseudo- lordosis at the base of the posterior spine (which is restricted to the L5-S1, and possibly L5-L4, area) and other common postural illusions for a true lordosis of the entire lumbar spine. (See Figure 7.15b.) Posterior Fibers of Psoas Also complicating lower-back pain, though not all of them are directly attached to the lumbar vertebral bodies, are the deepest, most posterior long fibers of the psoas major. These fibers run

15 178 CHAPTER 7 ANTERIOR TORSO COMPARTMENT (ATC) upward from their insertion at the lesser trochanter to their origin, attaching to the anterior transverse processes of the lumbar vertebrae and iliolumbar ligaments. If these fibers are excessively and chronically contracted, their pulling force on these ligaments (ligaments being significantly more pain-sensitive than muscle fibers) could be a significant source of pain. Lumbar Pain Pattern The iliopsoas, abdominals, hamstrings and the erector spinae, multifidus, rotatores and quadratus lumborum muscles are often the culprits of a failed low back and/or chronic pain because they can generate opposing forces on the pelvis, sacrum and lumbar vertebrae, and intervertebral disks. Prolonged sitting with the hips acutely flexed will cause the iliopsoas to adaptively shorten. This, plus reactive forces from opposing muscles, creates compression, stress, and vertical pain along the spine (lamina groove) and sacroiliac joints. Secondary pain of the iliopsoas muscle will likely be present at the insertion sites on the lesser trochanter of the femur and on the anterior thigh and groin. A hypertense psoas major also contributes to the so-called hip-click phenomena as well. Asymmetrical imbalances of the iliopsoas may contribute to a compensatory lumbar scoliosis. Both skeletal and myofascial asymmetries can be structural or functional and can occur in the lower C Pars vertebralis: Deep, superior portion (in green), small bridges between bodies of T-12 thru L-5. Fully covered by portion A of psoas major. T-12 L-1 L-4 B Deep, posterior portion (in red) of psoas major, originating at transverse processes of L-1 through L-5, and iliolimbar ligaments A Superficial, anterior portion (in purple) of psoas major, originating at vertebral bodies & intravertebral discs of T-12 through L-4 or L-5 Iliopubic eminence Iliopsoas tendon Lesser trochanter & attachment (insertion) of deep & superficial portions of psoas via the iliopsoas tendon Femur FIGURE 7.15a Pars vertebralis

16 CLINICAL MASSAGE THERAPY AND STRUCTURAL BODYWORK 179 Pseudo-Lordosis Produced in part by Psoas Major, (see Figure 7.15a) as it flexes the lumbar vertebral bodies, flattening the curve from T 12 through L 4 or L 5 Thoracic Kyphosis: The greater the Thoracic Kyphosis (upper spine curving toward rear), the greater the ILLUSION of a deeper Lumbar Lordosis T6 T12 T-12 Loss of Lumbar Curve from T 12 to L 4 L1 Psuedo-Lordosis: Looks like a curved scoop, but actually is an angle. Flesh stretched over the lumbar and pelvic region masks the positioning and angle of the bones. There are several possible variations in how this appearance of a scoop shows up. Gluteal Curve: The more well-developed the Gluteus Maximus is (by either muscle or fat), the greater the scooping and illusion of excess lumbar lordosis Gluteus maximus Hip Extension: Lateral Rotators, & Gluteals, Hamstrings, and Adductor Magnus Contraction closes angle toward rear of joint, TENDING toward pushing pelvis forward in space (anterior SHIFT) and to posterior TILT of pelvis. However, high tonus in hip flexors can counter-tighten and neutralize tendency toward anterior shift and posteriot tilt. L5 L-5 L 5/S 1 Compression & Shearing Action (sliding down and forward) creates an angle (see Angle on posterior side) where sacrum meets L-5, producing compression and shearing action (sliding down and forward). Produces limited and localized extension at L-5/S-1. In pseudo-lordosis, pelvis may be vertical (neutral) or slightly anterior tilted. Anterior Shift of Pelvis: Closing of angle between pelvis & femur on back (posterior) side is produced by hip extensors.... The resulting anterior SHIFT is often mistaken for an anterior TILT. Downward force of Psoas Major: creating lumbar flexion of T-12 thru S-1 and compression and shearing action at L-5/S-1 and L-4/L-5. Hip Joint SHIFTED anterior of center line through front of lateral maleolus. A pseudo-lordosis appears as a deep curve (exaggerated lordosis) of the lumbar spine. Yet often, this is a false illusion as to what is actually occurring in the positioning of the bones. Even with an appearance of an exaggerated lordosis or so-called sway back from thoracic region to buttocks, many people in reality have a loss of curve, a straightening, of the actual lumbar vertebrae fromt 12 to L 4. The overlying flesh often masks the true picture of what is actually occurring structurally (relationship between the bones). Treating such cases by tucking the pelvis or sacrum, flattening the low back, prematurely releasing the tension on the posterior lumbar spine, and other such actions further compresses the lumbar vertebral discs. FIGURE 7.15b Pseudo-Lordosis

17 180 CHAPTER 7 ANTERIOR TORSO COMPARTMENT (ATC) lumbar spine, pelvis, and/or lower extremities. For example, unless countered by an opposing muscle, a hypertonic iliopsoas muscle may cause a client to lean toward the hypertonic side, further involving the obliques, quadratus lumborum, erector spinea and latissimus dorsi muscles on the same side. ROUTINE: Iliopsoas Treating the abdominal muscles before treating the iliopsoas is recommended, as the tension in a hypertonic abdominal muscle can prevent lengthening of the iliopsoas. Position of client: supine. 1. If pain is present in the lumbar and sacroiliac region, bend the knee and laterally rotate and abduct the thigh. Initially, your knee could be used as a temporary bolster while accessing the iliacus and psoas. It is important that the client is comfortable and the abdominal wall is relaxed. Apply compression and slow, deep effleurage to the abdominal wall separating the muscular divisions. (See Figure 7.16.) 2. Place the fingertips just lateral to the rectus abdominis. Use circular pressure to penetrate slowly, gradually proceeding deeper toward the spinal column. Synchronize the circular movements with the client s breathing to help avert her natural tendency to guard against abdominal penetration. (See Figure 7.17.) When the client communicates comfort, proceed into deeper layers, maintaining the client s edge. No pain means more gain. 3. To isolate the psoas major, keep the hands in the same place and have the client contract the psoas muscle by flexing the hip toward the chest. Resist the movement at the same time. Once the psoas has been isolated, have the client relax. Using contoured fingertips, explore as much of the psoas as possible from the inguinal ligament, moving superior toward the rib cage. (See Figures 7.18 and 7.19.) Using the edge technique, treat with compression and subtle friction. Suggest that the client use hand signals to ensure effective communication. 4. Using the fingertips of both hands, treat the iliacus muscle where it merges with the psoas major muscle, along the inner surface of the ilium. Penetrate toward the therapy table, staying along the inner surface of the ilium. Periodically have the client contract the iliopsoas group to verify the location. (See Figure 7.20.) Bend the knee and laterally rotate and abduct the thigh. 5. Outline the length of the psoas with both hands. Using fingertips and/or contoured hands, apply compression with one hand while the other glides away, applying a deep myofascial stretch. With the fingertips, continue FIGURE 7.16 FIGURE 7.17 FIGURE 7.18

18 CLINICAL MASSAGE THERAPY AND STRUCTURAL BODYWORK 181 deep-gliding effleurage up to and as far under the inguinal ligament as the client will allow. (See Figure 7.21.) As the iliopsoas releases, lengthen it further by hanging the client s leg off the therapy table. Be sure to stabilize the leg. Repeat the routine if necessary. FIGURE 7.19 FIGURE 7.20 FIGURE 7.21 PECTORALIS MAJOR, FIGURES 7.22 AND 7.23 ORIGIN Clavicular head: medial half of clavicle Sternal head: sternum from manubrium to zyphoid process Costal head: first six costal cartilage surfaces INSERTION Lateral lip of bicipital groove of humerus ACTION Adduction, flexion, medial rotation of humerus; depression of arm and shoulder MYOTOME C5 T1 PECTORALIS MINOR, FIGURES 7.24 AND 7.25 ORIGIN Anterior 3rd, 4th, and 5th ribs near costal cartilage INSERTION Coracoid process of scapula ACTION Protracts, depresses, downwardly rotates scapula MYOTOME C8 T1

19 182 CHAPTER 7 ANTERIOR TORSO COMPARTMENT (ATC) Pectoralis major muscle FIGURE 7.22 Pectoralis Major Muscles Pectoralis major pain pattern Pectoralis major pain pattern FIGURE 7.23 Pectoralis Major Muscle and Referred Pain Patterns Subclavius Pectoralis minor FIGURE 7.24 Pectoralis Minor and Subclavius Muscles

20 CLINICAL MASSAGE THERAPY AND STRUCTURAL BODYWORK 183 Pectoralis minor pain pattern FIGURE 7.25 Pectoralis Minor Muscle and Referred Pain Pattern SUBCLAVIUS, FIGURES 7.24 AND 7.26 ORIGIN 1st rib costocartilage junction INSERTION Middle third of inferior surface of clavicle ACTION Depression of shoulder; stabilization of clavicle during shoulder movement MYOTOME C5, C6 Subclavius pain pattern Subclavius pain pattern FIGURE 7.26 Subclavius Muscle and Referred Pain Patterns

21 184 CHAPTER 7 ANTERIOR TORSO COMPARTMENT (ATC) CLINICAL NOTES: Pectoralis Major, Pectoralis Minor, and Subclavius The pectoralis minor originates on the 3rd, 4th, and 5th ribs and attaches to the coracoid process of the scapula. The subclavius lies on the inferior surface of the clavicle, traveling most of its length and attaching to the 1st rib. The pectoralis major is superficial to both the pectoralis minor and the subclavius. There are three divisions of this muscle clavicular, sternal, and costal which originate at different locations, run in different directions, and insert at the same point: the bicipital groove of the humerus. Because of the varied directions that its three divisions travel and their attachment on the humerus, the pectoralis major influences many movements of the humerus, including flexion, adduction, and medial rotation of the arm, as well as depression of the arm and shoulder. The pectoralis minor assists the serratus anterior in forced inspiration and contributes to protraction, depression, and downward rotation of the scapula. The subclavius stabilizes the clavicle and assists in depression of the shoulder. Anterior shoulder pain, breast pain, and diffuse soreness are symptoms of trigger point pain referred by the pectoralis muscles. Pain in the shoulder that traces down the arm and into the hand could be a sign of thoracic outlet syndrome: a condition in which the cervical spine compresses toward the rib cage because of anterior cervical muscles and the pectoralis minor s pulling the shoulder down from the front, thus narrowing the space between the cervical spine and the 1st rib. Also contributing to thoracic outlet syndrome is the latissimus dorsi s pulling the shoulder down from the back and, therefore, pulling the clavicle down and back against the 1st rib. These muscular imbalances can compress and entrap the neurovascular structures exiting and entering the neck, chest, and arm; if left untreated, they can lead to pain, motor weakness, immobility, and atrophy of the shoulder and upper extremity. Dr. Janet Travell, coauthor of Myofascial Pain and Dysfunction, Volume I, refers to the pectoralis major as the heart attack muscle. According to Travell, cardiac arrhythmia trigger points may be located on the right side, 1 inch lateral to the xiphoid process and 2 inches superior, between the 5th and 6th ribs. The referral pain from these trigger points can replicate the intensity, quality, and distribution of true cardiac pain. Travell has a second nickname for the pectoralis major: the poor posture muscle. A stooped posture is aggravated by the increased tension caused by myofascial trigger points in the pectoralis major muscle. Increased tension in the anterior torso muscles that results in stooped posture causes the rib cage to be pulled down and forward; this causes the pectoral muscles to adaptively shorten. This pulls the shoulders inward, rounding the shoulders. As this kinetic chain, initiated by the abdominals, shortens, the neck and head move forward and down, further shortening the anterior neck muscles. The farther the neck and head move forward off the gravitational line, the more the suboccipital muscles compress. This tightening at the base of the occiput is the body s last-ditch effort to hold the head upright, leveling the eyes to the horizon. Poor sitting postures arise from inadequate lumbar support. A lumbar support (e.g., a rolled-up towel placed in the small of the

22 CLINICAL MASSAGE THERAPY AND STRUCTURAL BODYWORK 185 back) will cause the pelvis to rotate anteriorly, facilitating a lumbar curve and taking pressure off the lumbar disks. This natural curve (lordosis) will pull the upper body back on plane, increasing the natural curve of the neck and opening up the chest, thereby facilitating a more efficient posture. The three divisions of the pectoralis major should be treated independently with treatment directed into the muscle bellies and toward their attachment on the humerus. Treatment to the pectoralis major should also include the subscapularis, latissimus dorsi, teres major, serratus anterior, and abdominal musculature in order to separate and identify any areas of restriction. Note: The chest wall is a highly sensitive area for most people; the cervical and axillary lymph nodes drain in the chest, where there can be metabolic waste accumulation, causing hypersensitivity. ROUTINE: Pectoralis Major, Pectoralis Minor, and Subclavius Position of client: supine, with the client s arm extended away from the body. Support the arm with an extended bolster if the arm does not fit on the table, but allow the client s hand to hang off the table. (See Figure 7.27.) 1. Treat the anterior torso compartment with slow, deep effleurage from the pubic bone, over the rib cage, and superiorly in a fan-shaped pattern through the sternal and pectoral region, ending at the clavicles. 2. Using the fingertips, apply compression and friction along the muscle fibers, separating the three muscular divisions of the pectoralis major. 3. Using the fingertips, slowly compress downward and apply slow, rhythmical friction to the pectoralis minor by treating the pectoralis major. (See Figure 7.28.) 4. Isolate the pectoralis major by picking it up, off the rib cage. Treat with compression. Using thumbs and fingers, friction in 1-inch segments. (See Figure 7.29.) 5. Using a collapsed fist, treat the pectoralis major from the sternum to the humerus with deep, slow effleurage. 6. Contour one hand along the lateral rib cage, and slowly apply inward compression into the pectoralis minor while the other hand lightly lifts the pectoralis major. (See Figure 7.30.) FIGURE 7.27 FIGURE 7.28

23 186 CHAPTER 7 ANTERIOR TORSO COMPARTMENT (ATC) 7. Maintain the same contoured hand position. Glide superiorly toward the coracoid process while lifting the arm toward the ceiling and pulling it posteriorly to stretch the myofascia. Compress the fingers down on the pectoralis minor. Hold static compression in 1-inch segments. Use the edge technique for maintaining the client s comfort. (See Figure 7.31.) Have the client move to the side-lying position to ensure that the pectoralis major is off the rib cage, exposing it and the pectoralis minor for treatment. Sit at the side of the table at the client s waist. Place the client s arm out in front of his or her body. 8. Place one hand around the client s scapula. Place the other hand underneath the client s arm, and grasp the pectoralis major. Treat with slow, firm petrissage, exploring the muscular divisions. (See Figure 7.32.) Face the palm toward the rib cage, and point the fingers inward. Separate the pectoralis major from the underlying pectoralis minor muscle, and slowly compress the pectoralis major in 1-inch segments. Move, and reenter the compression. Using a contoured hand, treat the pectoralis minor along the rib cage with compression and circular friction. Use the edge technique for maintaining the client s comfort. (See Figure 7.33.) 9. Allow the client s arm to roll forward so that the clavicle lifts off the upper ribs. Using the fingertips of one hand and the thumb of the other, treat the subclavius muscle underlying the clavicle with static compression. Apply friction in 1-inch segments. (See Figure 7.34.) 10. Using the fingertips, glide along the inferior border of the clavicle and re-treat the pectoralis major around the attachment and the subclavius muscle, as shown in Figure FIGURE 7.29 FIGURE 7.30 FIGURE 7.31 FIGURE 7.32

24 CLINICAL MASSAGE THERAPY AND STRUCTURAL BODYWORK 187 FIGURE 7.33 FIGURE 7.34 SERRATUS ANTERIOR, FIGURES 7.35 AND 7.36 ORIGIN Upper nine ribs INSERTION Anterior vertebral border of scapula ACTION Protracts scapula; rotates scapula upward MYOTOME C5 C7 Serratus anterior FIGURE 7.35 Serratus Anterior Muscle

25 188 CHAPTER 7 ANTERIOR TORSO COMPARTMENT (ATC) Serratus anterior Serratus anterior pain pattern Serratus anterior pain pattern Serratus anterior pain pattern FIGURE 7.36 Serratus Anterior Muscle and Referred Pain Patterns CLINICAL NOTES: Serratus Anterior The serratus anterior anchors the scapula to the thorax, originating on the upper nine ribs and attaching on the entire anterior vertebral border of the scapula from the inferior angle to the superior angle. The lower fibers of the serratus anterior interdigitate with the upper fibers of the external oblique where they attach to the lower ribs. These fibers can pull the inferior angle of the scapula forward, causing the scapula to rotate upward elevating the shoulder girdle. From a posterior view, the vertebral border of the scapula will appear to protrude from the body. The primary function of the serratus anterior is protraction of the scapula, assisted by the pectoralis minor and upper fibers of the pectoralis major. The serratus anterior also assists the upper fibers of the trapezius, rhomboids, and levator scapulae in elevating the scapula; therefore, an abnormally protracted or an elevated scapula may be a clinical indication for treating the serratus anterior muscle. Shortening of the pectoralis major, pectoralis minor and the serratus anterior is often the result of stooped posture and can cause rounding of the shoulders, pain in the anterior and lateral chest wall, and a restricted expansion of the chest wall on inspiration. If the pain is perpetuated by a forced protraction of the shoulder, it is likely that the serratus anterior is involved.

26 CLINICAL MASSAGE THERAPY AND STRUCTURAL BODYWORK 189 ROUTINE: Serratus Anterior Position of client: side-lying. 1. Using the fingertips, treat the lateral torso with slow, deep effleurage; stretching the myofascia from the iliac crest to the axilla, continuing to the olecranon processes of the ulna. (See Figure 7.37.) 2. With a contoured hand and the fingertips, glide along the rib cage, simultaneously compressing the serratus anterior onto the rib cage. (See Figure 7.38.) Position the other hand under the vertebral border of the scapula. Glide both hands toward each other, simultaneously lifting the scapula toward the ceiling. Perform movement palpation (protraction and retraction) of the scapula. 3. Using flexed fingertips, treat the underlying surface of the vertebral border of the scapula with friction in 1-inch segments. (See Figure 7.39.) 4. Using fingertips, treat along the upper nine ribs with compression and slow, deep effleurage. Then apply a broad, slow and isolated friction in 1-inch segments. (See Figure 7.40.) 5. Using the fingertips, treat the muscles along the lamina groove with friction while retracting the shoulder girdle for easier access. (See Figure 7.41.) FIGURE 7.37 FIGURE 7.38 FIGURE 7.39 FIGURE 7.40 FIGURE 7.41

27 190 CHAPTER 7 ANTERIOR TORSO COMPARTMENT (ATC) CERVICAL MUSCLES Prior to treating the cervical muscles, treat the compartment distortions from the originating sources, which lead up to and affect the muscles of the neck. Important: By now, a complete postural assessment and palpatory examination of the client s posture and compartment imbalances should have been done and understood. This helps to clarify the client s pain patterns and perpetuating factors, which provide the therapist with a specific plan of treatment, especially if the client s pain has been chronic. Chronic neck pain in the back of the neck is often experienced when a loss of cervical curve or straightening of the cervical spine is present. In severe cases the cervical spine actually reverses. The farther the spine straightens or reverses, the more downward force is applied to the disks in front. This causes the disks to migrate posterior and lateral, often protruding into the nerve roots where the nerves exit the neural foramina of the spine. The deep primary flexors and lateral flexors of the neck (longus colli, longus capitis, and scalenes), discussed in this chapter, are highly important to isolate and treat as it is these muscles that cause the majority of chronic neck and upper-extremity pain associated with loss of cervical curve. Treating the superficial muscles first and then the deeper primary flexors will allow for easier access into the deeper levels toward the vertebral bodies of the spine. Chasing a client s pain (i.e., treating only where it hurts) often produces only temporary results. As stated above, the majority of people s pain is located in the back of the neck because of straightening of the spine and often a downward collapsed, stooped posture. Therefore, treating the secondary contractors, the ones resisting the primary contractors, will loosen them up only temporarily, and this will then cause the deeper anterior muscles to shorten even more, as they take up slack. Much of the time, it will even cause the pain to actually get worse. Treating the anterior neck muscles and then releasing the posterior suboccipitals will provide many positive benefits, such as restoring cervical lordosis, decompressing the spinal disks, putting the neck and head back on the proper plane (viewed from the side, ear over shoulder), freeing up the C1 and C2 suboccipital joints, and decreasing the intensity and frequency of the neck pain. Quite often, lengthening the hamstrings and abdominal muscles alone will upright the body significantly, thereby decreasing the cervical pain symptoms considerably. STERNOCLEIDOMASTOID, FIGURES 7.42 AND 7.43 ORIGIN 1. Manubrium of the sternum; 2. medial clavicle INSERTION Mastoid process ACTION Bilateral: flexion of neck; elevation of sternum on deep inspiration Unilateral: lateral flexion of neck; rotation of head to opposite side MYOTOME C3, C4